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Phase 4 > MSK > Flashcards

MSK Flashcards

1
Q

If someone present with severe back pain, usually around the thoracic area, and has a fever and respiratory symptoms, what is a likely diagnosis?

A

Pott’s disease of the spine

- secondary to TB infection

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2
Q

If a patient presents with a history of increasing back pain and fever, what should you suspect and how is it diagnosed and treated?

A

Dicitis

Diagnosis:
MRI
CT guided biopsy

Treatment:
6-8 weeks IV Antibiotics
+
Infective endocarditis scan

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3
Q

What back pathology typically presents with worsening of pain:

  • in the morning
  • extension movement
A

Facet Joint Pain

  • straight leg test will be negative.
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4
Q

If a patient presents with fever and severe pain that is getting worse in their:

  • lower back
  • radiating into their thigh and groin

the patient finds the pain is relieved somewhat by lying down and flexing their legs.
What is a likely diagnosis?

A

Psoas Abscess

Primary: haematogenous spread from distant site

Secondary: spread from local sources: crohn’s, diverticulitis, GU infections, endocarditis

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5
Q

If there is a disc prolapse at level 4/5 which sensory root will be affected?

A

Dermatome 5

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6
Q

What is the general Management for lower back pain?

A

Analgesia

  • NSAIDs
  • Paracetamol

Muscle relaxants
- diazepam (if needed)

Early mobilization

Physiotherapy

Cognitive behaviour therapy

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7
Q

Which primary tumour will show a codman’s sign on x-ray?

A

Osteosarcoma

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8
Q

What disease may lead to osteosarcoma?

A

Paget’s disease

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9
Q

How is osteosarcoma diagnosed and what other place should be imaged? and how is it treated?

A

High resolution CT

Image the Chest - the cancer spreads to lungs early

Treatment:

  • 8 weeks chemotherapy
  • amputation
  • continual chemotherapy
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10
Q

Where does osteosarcoma usually present?

A

Metaphysis of long bone

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11
Q

Which tumour may have the onion sign on xray?

A

Ewing’s sarcoma

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12
Q

Why should chondromas be removed?

A

They can become malignant and transform into chondrosarcomas

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13
Q

What is the management for chondrosarcomas?

A

Only surgical

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14
Q

What are some of the complications of Paget’s disease?

A

Pathological fractures

Hypercalcaemia

Nerve compression

Deafness

Osteosarcoma

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15
Q

What are the characteristic findings of the hands with OA?

A

Heberden’s nodes - DIPJ

Bouchard’s Nodes - PIPJ

Squaring of the base of thumb - CMJ

Weakened grip

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16
Q

What is the management for OA?

A

Lifestyle advice + strengthen exercises

physiotherapy

Analgesics:
1st line: Paracetamol + topical NSAIDs

2nd line: Oral NSAIDs + PPI

3rd Line: Opioids + steroid injections

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17
Q

What is the diagnostic criteria for OA?

A 
Diagnosis can be made clinically if: 
>45 years old 
Signs and symptoms 
\+ 
No stiffness over 30mins in morning
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18
Q

What are some extra articular manifestations of RA?

A

Pulmonary fibrosis
Pulmonary nodules
pleurisy

Episcleritis
Scleritis
Corneal ulceration

Vasculitis

Nodules

Felty’s syndrome

Depression

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19
Q

What x-ray changes can be seen in Ankylosing Spondylitis?

A

Squaring of vertebral bodies

Subchondral sclerosis

Syndesmophytes
- ligament calcification

Subchondral erosion

Fusion

  • facet joints
  • sacroiliac joints
  • costovertebral joints
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20
Q

What is the management of ankylosing spondylitis?

A

Physiotherapy
Smoking cessation

1st Line:

  • NSAIDs
  • naproxen
  • steroids for flares

2nd line:
- TNA alpha inhibitors

3rd line:

  • Secukinumab
  • surgery
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21
Q

What is a IL-17 inhibitor used in ankylosing spondylitis?

A

Secukinumab

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22
Q

What are some complications of Ankylosing spondylitis?

A

Bamboo spine

Vertebral fractures

Lung fibrosis
- apex of lungs

Heart block

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23
Q

What is an important clinical test to be done for Ankylosing spondylitis that suggests severe restriction in the lower spine?

A

Schober’s test
This is when the L5 is marked, then 10cm above is marked and 5cm below.
The patient then bends forward.

If the distance between them is <20cm then this shows there is a restrictive movement disorder. Helping support SA.

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24
Q

What are the crystals seen in pseudogout? and how do they appear under microscopy?

A

Calcium pyrophosphate crystals

Positively bifiregent and rhomboid

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25
Q

What are the crystals in gout and how do they appear?

A

Monosodium urate crystals

Negatively bifiregent, needle shaped

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26
Q

What is the long term treatment of gout?

A

Allopurinol

  • start 3 weeks after attack
  • increased every 4 weeks until the target level of urate acid is reached

Febuxostat
- if allopurinol not tolerated

Uricosuric agents
- promote excretion of urate acid

stop use of predisposing factor

  • thiazides
  • losartan
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27
Q

When investigating gout what additional tests should be done beyond the joint aspiration?

A

Biochemical screen

  • Renal function
  • Lipid profile
  • glucose levels
  • uric acid level

These should be done because of the association between metabolic syndrome and gout.

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28
Q

What should the patient be warned off when starting urate lowering drugs such as allopurinol?

A

That increased bouts of gout may occur initially and to continue with the treatment. Therefore should be on NSAIDs as well to cover.

29
Q

What additional management outwith medication should be done for patients suffering with gout?

A

Lifestyle factors

  • loose weight
  • reduce alcohol intake - especially beer
  • maintain good hydration
  • avoid high purine diets - seafood, red meats
  • stop thiazides - swap for ACE inhibitors
30
Q

What blood markers are typically elevated in acute gout?

A

ESR
CRP
Neutrophils

31
Q

What clinical findings may be seen on a knee with OA?

A

Varus deformity

Joint line/ periarticular tenderness

Weakness and wasting of quadriceps

Restricted movement

Bony swellings around joint

32
Q

What is the most sensitive sign for hip OA?

A

Pain and restriction of internal rotation of the hip when flexed

33
Q

What are some risk factors towards septic arthritis?

A

Immunocompromised

Prosthetic joint

Damaged joint

  • RA
  • Previous Septic arthritis

IVDU

Diabetes

Localised ulceration

34
Q

What features of septic arthritis would point towards the infection being a disseminated STI?

A 
Sexually active young person 
History of STI 
Migratory arthralgia
Polyarthralgia 
Low grade fever  
Painful pustular skin lesions
35
Q

What is the general management for Septic arthritis:

A

Following investigations, Joint aspiration, bloods.

Sepsis 6:
- IV antibiotics. - 2 weeks IV, 4 weeks oral

Daily aspiration of joint or surgical drainage

If prosthetic then orthopaedics are needed for DIAR or removal

Physiotherapy early on
- passive movement of joint

36
Q

What is the triad of symptoms seen in reactive arthritis?

what is the management?

A

Reiter’s syndrome

  • urethritis
  • arthritis
  • conjunctivitis

NSAIDs/ intra articular injections
consider methotrexate if > 6 months

37
Q

What are two major complications of bisphosphonates?

A

Acid reflux
- should be avoided in achalasia or strictures due to ulceration affect

Osteonecrosis of the Jaw
- should be withheld during dental work

Atypical Bone fractures
- especially of the hip

38
Q

What pharmacological management is available for osteoporosis?

A

Vit D and Calcium supplements

Bisphosphonates

Denosumab

Teriparatide
- PTH recombinant

HRT

39
Q

What are the T scores ranges?

A
  • 1.5 to -2.5: Osteopenia

- 2.5> : osteoporosis

40
Q

Where does the DEXA scan usually look at?

A

Lumbar spin

Hip

41
Q

Outwith DEXA scan what additional tests do you want to perform in osteoporosis?

A
  • FBC
    • TFTs
    • Vitamin D
    • PTH levels
    • Coeliac screen
    - Can affect calcium reabsorption• Gonadotrophins
    If early onset, especially in males

Good history of previous fractures, and risk factors

42
Q

what medication is allopurinol contraindicated with?

A

azathioprine

cause bone marrow suppression

43
Q

How is Paget disease treated?

A

Bisphosphonates

Calcitonin

44
Q

How is Paget’s disease investigated?

A

Bloods:

  • ALP
  • C- Telopeptide (bone turnover)

X-ray
- slcerotic bone

Isotope uptake scan

45
Q

What are the associated symptoms of Ankylosing spondylitis?

A

A’s

  • Apical fibrosis in lungs
  • Anterior uveitis
  • Aortic regurgitation
  • Achilles tendonitis
  • AV node block
  • Amyloidosis
46
Q

Outwith Reiter’s syndrome what other clinical finding may point towards reactive arthritis?

A

dactylitis

47
Q

What are the red flags of back pain?

A

<20 years of age, >50 years

worse at night and morning

Associated with systemic illness/ Fever

Weight loss

Previous/ active malignancy

Associated with neurological symptoms

48
Q

What are the risk factors for recurrence of back pain?

A 
Female 
Increasing age 
Pre-existing chronic pain 
Psychological factors - distress 
Unemployment
49
Q

What treatment can be done into vertebral crush fractures?

A

Vertoplasty
- cement

Kyphoplasty
- balloon

50
Q

Name some differentials into a swollen joint in a child:

A

Hemarthrosis
Septic
Juvenile idiopathic arthritis
Reactive arthritis

51
Q

What Examination do you want to do into a swollen joint?

A 
Assess temperature
Look for erythema 
Check ROM 
Compare against other knee
Look at patient systemically - are they well
52
Q

What are clinically findings of hands in rheumatoid disease?

A

Symmetrical
Z deformity of thumb
Prominent ulnar
Swelling of PIPJs and MCPJs

53
Q

Why might a RA patient have clubbing of fingers?

A

Interstitial lung disease

methotrexate use

54
Q

What are some complications of hip joints?

A

loosening of joint

Septic arthritis

Dislocation

55
Q

What is a common cardiac manifestation of RA?

A

Pericarditis

56
Q

What are the differentials for septic arthritis?

A

Gout

Haemarthrosis

Cellulitis

Psoriatic arthritis

57
Q

The fluid aspirated from an infected joint should be sent away for what?

A

Crystal Microscopy
Gram staining
Cultures
Sensitivities

58
Q

What is the management of septic arthritis?

A

IV Flucloxacillin
+/-
IV Gentamicin

or
IV Vancomycin if MRSA or allergic

2 weeks IV, 4 weeks PO

Surgical:

  • irragation
  • wash out
59
Q

What are some of the risk factors for OA?

A

Family history

Obesity

Occupation

Hyperflexibility

Trauma

60
Q

What are some of the secondary causes of OA?

A

Intra-articular fracture
Avascular ncesosis
Paget’s disease
Haemochromatosis

61
Q

What are the surgical interventions that can be done for OA?

A

Osteotomy - removal

Arthroplasty - joint replacement

Arthrodesis - fixation

62
Q

What are some non medical interventions into OA?

A

Lifestyle changes
- weight loss
Insoles - cushioning

Walking aids

Knee braces

TENs machine

Physiotherapy

63
Q

What is the definition of osteoporosis

A

Low bone mass
Micro-architectural deterioration
increased risk of fragility fracture

64
Q

How is osteoporosis differentiated from osteomalacia?

A

Osteoporosis has normal mineralisation whereas osteomalacia does not

65
Q

What are the risk factors for osteoporosis:

A

Menopause

Low calcium

Alcohol

Smoking

Steroid use

Physical inactivity

Hypogonadism in men

66
Q

What is a screening method prior to DEXA scan for osteoporosis?

A

Quantitative Ultrasound

67
Q

What does the T and Z score stand for in Osteoporosis?

A

T score - Bone density compared against a healthy 30 year old of same gender

Z score - Bone density compared against some of the same age, gender and ethnicity

68
Q

How many NSAIDs need to be used before TNF alpha is started in the management of Ankylosing spondylitis?

A

2 NSAID trials.

then move to TNF alphas

Phase 4 (49 decks)

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